Cases & Commentaries

Admitted to the hospital for treatment of a hip fracture, an elderly woman with end-stage dementia was placed on the hospice service for comfort care. The physician ordered a morphine drip for better pain control. The nurse placed the normal saline, but not the morphine drip, on a pump. Due to the mistaken setup, the morphine flowed into the patient at uncontrolled rate.

Legislation/Regulation > Organizational Policy/Guidelines

Miscalculations of intravenous infusion concentrations can result in patient harm. Representing the first phase of a standards development project, this report describes how standardization can improve reliability and safety of intravenous therapy and provides guidance on safe concentrations for drugs.

Journal Article > Study

When pharmacists make up an individually prepared solution of liquid medication (a process known as compounding) for a pediatric patient, there is a risk for dosing error. This pre–post study demonstrated that implementing a standardized protocol for liquid medication compounding for children was well-received and widely adopted by pharmacists.

Journal Article > Study

Mistakes during preparation of intravenous (IV) medications can lead to dosing errors and adverse drug events. Analyzing data collected over 12 months in a hospital's automated IV compounding workflow management system, this study found that IV compounding errors occurred in less than 1% of cases and were usually intercepted through the automated system. These results suggest that existing processes do support safe medication use.

Cases & Commentaries

An attending physician recommended using acetic acid to evaluate a lesion on the perineum of a woman who had previously experienced a wart in the same area. The resident physician asked the medical assistant for acetic acid and unknowingly received trichloroacetic acid, which burned the patient's skin.

This survey of pharmacists in New Zealand revealed that they believe pharmacy technicians could conduct many of the mechanical aspects of medication dispensing so that pharmacists could spend more time with medication counseling, which has been shown to enhance medication safety. This work adds to the literature supporting the use of teams to improve patient safety.

Newspaper/Magazine Article

Dispensing errors in the community setting are a frequent source of concern. This newsletter article describes how correctly completed medication orders can inadvertently be given to the wrong patient in the community pharmacy setting and reviews steps patients can take to avoid receiving the incorrect medication.

Standard use of metric oral dosage instructions has been advocated as a medication safety strategy. Raising concerns around dosing cups that include drams and ounces as scales—measures no longer in clinical use—which are available from major vendors and may be found in health care facilities, this announcement recommends use of oral syringes that only measure in milliliters for oral liquid medications to prevent errors.

Vaccination-related errors reported to the National Vaccine Adverse Event Reporting System grew from 10 in the year 2000 to 4324 in 2013, potentially due to the introduction of new vaccines, increasingly complex vaccination schedules, and changes in reporting practices. The most common errors were dispensing vaccines at an inappropriate schedule or administering expired or incorrectly stored vaccines. One-fourth of reported errors caused an adverse health event, with 8% of these resulting in serious harm.

Cases & Commentaries

Admitted to the hospital with chest pain, headache, and accelerated hypertension, an older man with a history of chronic kidney disease and essential hypertension who had missed several days of his regular medications was to be started back on them gradually. One of his antihypertensive medications (minoxidil) was ordered via the EHR, but a vasopressor/antihypotensive medication with a similar name (midodrine) was dispensed. Fortunately, a nurse noticed the discrepancy before administration.

Journal Article > Study

Implementation of a safe zone—which included marked quiet areas for medication preparation, adhering to a checklist for medication processes, and educating staff about distractions—to minimize interruptions during medication administration did not improve medication error rates, but was associated with an increase in patient satisfaction.

Journal Article > Study

This single-hospital study explored the practice of medication dispensing by physicians. Although physicians were commonly expected to dispense medications, especially in the emergency department, some participants felt insufficiently trained to perform this task.

Audiovisual

This video news segment reports how incorrect medications can be dispensed from pharmacies, notes a lack of regulation mandating that pharmacy errors are reported, and offers tips for patients to reduce risks.

This qualitative study characterized safety hazards in medication dispensing in community pharmacies. The authors conclude that the major sources of risk pertained to interruptions and distractions, which were often exacerbated by production pressures.

This internet-based survey of pharmacists in the United Kingdom revealed an association between self-reported medication dispensing errors and higher perceived workload, similar to prior nursing studies. These findings contrast with earlier research that showed no relationship between physician working conditions and errors.

Cases & Commentaries

On multiple oral medications and a depot injection (dispensed by a separate specialty pharmacy and administered at a clinic), a patient with schizophrenia was mistakenly given the depot injection kit by his local pharmacy and injected it himself.

Journal Article > Study

Pediatric inpatients are at high risk for adverse drug events (ADEs). Pediatric-specific trigger tools and computerized surveillance systems are effective methods to detect ADEs and identify opportunities for prevention. This performance-improvement collaborative implemented a multifaceted change strategy in 13 institutions and produced a 42% reduction in ADEs. The change strategies included efforts to reduce interruptions during medication administration, adopt consensus-based protocols and order sets, ensure high reliability with the Five Rights, and foster a culture of safety. The interventions had the greatest impact on opioid-related ADEs, which decreased by 51% across participating hospitals. The authors recommend using quality improvement collaboratives to drive improved patient care.